Subarachnoid-pleural fistula treated with noninvasive positive pressure ventilation: a two-case report and literature review.

Study Design: A report on 2 cases of subarachnoid pleural fistula (SAPF) treated with noninvasive positive pressure ventilation (NPPV).

Objective: To highlight the efficacy of NPPV in patients with SAPF.

Summary Of Background Data: SAPF is a rare but distressing type of cerebrospinal fluid leakage. It is known to be a complication of anterior thoracic spine surgery. The pressure gradient between the subarachnoid space and the pleural cavity maintains the cerebrospinal fluid leakage and precludes the spontaneous closure of the dura. Surgical interventions such as primary repair, patch grafts, muscle flaps, and omental flaps have been advocated. Only limited reports were found with reference to NPPV applied to SAPF.

Methods: Two patients, a 45-year-old woman and a 39-year-old woman, underwent anterior thoracic spine surgery to treat thoracic myelopathy caused by ossification of the posterior longitudinal ligament. After surgery, they developed SAPF due to perforation of the dura during surgery. Placement of thoracostomy tubes and subarachnoid drains had no effect and an NPPV device was applied.

Results: During application of the NPPV device, 14 days in the first patient and 5 days in the second patient, the raised intrapleural pressure obstructed the fluid leakage and successfully treated the fistula. No recurrence of SAPF was observed after removal of the NPPV device and the patients avoided surgical interventions.

Conclusion: SAPF is often resistant to conservative therapies and has been treated in an invasive manner. NPPV should be considered as an alternative before such interventions because it is effective, noninvasive, and safe.